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Tuoyi (Treprizimab Injection) is the only PD-1 monoclonal antibody approved for the treatment of nasopharyngeal carcinoma in the world, and its research in head and neck tumors is progressing continuously.
In order to improve the understanding of the majority of oncologists on the immunotherapy of head and neck tumors, Dr.
Sun Yao from the Department of Radiotherapy at the Cancer Hospital of Tianjin Medical University shared a case of recurrent laryngeal cancer for readers.
Case profile Medical history and auxiliary examination: A 62-year-old male patient with a complaint of "Goiter was found for 2 weeks" and was admitted to the hospital on June 16, 2020.
History of present illness: A neck mass was found for 2 weeks to see a doctor.
A neck ultrasound showed a solid mass in the left lobe of the thyroid, which was suspiciously malignant.
The patient had no hoarseness, coughing and other discomforts.
Past history: Partial laryngectomy was performed in 2016 due to early glottic carcinoma.
During the operation, the right vocal cord + anterior joint + left vocal cord anterior part were removed en bloc.
Postoperative pathology showed: laryngeal squamous cell carcinoma.
Physical examination: There is a mass in the left thyroid area, about 3.
5cm×2.
5cm, with tough texture, clear borders, no tenderness, moving up and down with swallowing, and no obvious mass in the right thyroid.
Both necks are not significantly enlarged lymph nodes.
Auxiliary examination: B-ultrasound indicates a solid mass in the left lobe of the thyroid-suspicious malignancy (Grade 4b), combined with biopsy is recommended; a solid nodule in the upper and middle left lobe of the thyroid, considering the possibility of nodular goiter (Grade 3).
The treatment passed the first stage of treatment: considering the possibility of thyroid cancer, the left thyroidectomy + left central cervical lymph node dissection under general anesthesia was performed on June 18, 2020.
The postoperative pathology showed: (After laryngeal cancer, Left lobe of thyroid) squamous cell carcinoma, considered metastatic in combination with medical history, originated from the larynx; left deep lymph node of the neck (+) with vascular tumor thrombus; no cancer metastasis, soft tissue in the left central lymph node (+): 0/ 4.
Soft tissue (+).
Immunohistochemistry: P63 (+), CK5/6 (+), P16 (-), EGFR (+), Ki-67 (30-40%+).
On July 2, 2020, a PET-CT examination showed that after “laryngeal cancer” and “left thyroidectomy”, the left thyroid lobe was absent, and the left back of the larynx was equivalent to a soft tissue mass at the level of the original left thyroid lobe.
PET imaging shows radioactive concentration, which is considered to be metastasis, and the adjacent larynx wall is suspected to be affected, except for the trachea and esophagus.
Further bronchoscopy and esophagoscopy examination showed no abnormalities.
Figure 1 PET-CT examination results The second stage of treatment: from August 18 to September 24, 2020, local radiotherapy for recurrent lesions, using volumetric emphasis (VMAT) technology, PGTV 69.
96Gy/33F.
The PD-L1 test was performed, and the CPS score was 2.
During radiotherapy, two cycles of concurrent cisplatin chemotherapy (80mg/m2) and concurrent teriprizumab (240mg) were given.
The radiotherapy process went smoothly.
Figure 2 Cervical CT results of 50Gy radiotherapy during treatment review: comparison with the PET-CT results on July 2, 2020: the laryngeal, left posterior, and left thyroid masses are larger than before, and the trachea and esophagus are not affected.
There is no obvious change.
Figure 3 The results of PET-CT during radiotherapy at 50Gy were re-examined on November 2, 2020.
The results suggest that compared with the CT results of the neck on September 10, 2020, there are more tumors in the laryngopharyngeal and left posterior and left thyroid areas.
The front has shrunk, and there is no obvious change in the rest.
Figure 4 The results of the neck CT review on November 2, 2020.
On January 12, 2021, the PET-CT review showed complete remission.
The results of PET-CT showed that compared with the results of PET-CT on July 2, 2020, the soft tissues of the left side of the trachea and the trachea and the esophagus in the original operation area were reduced after the "left thyroid lobe metastasis".
This PET imaging The degree of radioactive concentration is lower than before, suggesting that the metabolism of the lesion is lower than before.
Figure 5 PET-CT reexamination results on January 12, 2021, the patient's single-agent teriprizumab treatment has been maintained so far.
Case analysis The patient is a relapsed laryngeal cancer.
He was diagnosed with early glottic laryngeal cancer 4 years ago and underwent radical surgery.
Recurrence of cervical lymph nodes occurred 4 years after surgery.
Because the metastatic lymph node invaded the left lobe of the thyroid, when I went to surgery, I mistakenly considered a goiter and underwent radical thyroidectomy.
The postoperative pathology suggested squamous cell carcinoma.
Considering metastasis based on the previous medical history, further PET-CT examination was performed to confirm that it was laryngeal cancer.
Postoperative recurrence, after radiotherapy combined with immunotherapy for the recurring lesions, complete remission was obtained, and subsequent immunotherapy has been maintained for 8 months.
This case is a successful trial of radiotherapy combined with immunotherapy in recurrent head and neck squamous cell carcinoma.
The main adverse reactions in patients with radiotherapy combined with immunotherapy were second-degree radiation mucositis and first-degree radiation dermatitis, which were mainly related to radiotherapy.
No aggravation of mucositis caused by radiotherapy combined with immunotherapy was observed, and no immune-related adverse reactions were observed.
Appears, overall safety and well tolerated.
Expert comments based on the results of KEYNOTE-0481, suggesting that for recurrent/metastatic head and neck squamous cell carcinoma, combined immune chemotherapy is better than traditional targeted combined chemotherapy in the whole population, and in patients with PD-L1 CPS≥1, PD -1 monoclonal antibody also outperforms the traditional EXTREME regimen, especially for patients with CPS ≥ 20, compared with standard treatment, the 4-year survival rate of PD-1 monoclonal antibody is nearly three times higher (21.
6% vs 8.
0%), with a median total The survival time was extended from 10.
7 months to 14.
9 months, reducing the risk of death from the disease by 39% (HR=0.
61).
Based on the conclusions of this study, the first-line treatment of recurrent and metastatic head and neck squamous cell carcinoma has been completely changed.
The first-line treatment plan of PD-1 monoclonal antibody or combination chemotherapy has also been recommended by experts in the 2021 version of the CSCO guidelines.
For patients with recurrent head and neck squamous cell carcinoma that can be treated with local radiotherapy, the exploration of radiotherapy combined with immunotherapy for recurrent foci is still in progress, and a number of studies are currently being enrolled.
This case preliminarily confirmed that radiotherapy combined with teriprizumab in recurrent head and neck squamous cell carcinoma achieved good results.
It is hoped that more studies can further confirm the effect of this treatment model and bring more benefits to patients with recurrent head and neck squamous cell carcinoma.
Benefit more. References; 1.
BURTNESS B, HARRINGTON KJ, GREIL R, et al.
Pembrolizumab alone or with chemotherapy versus cetuximab with chemotherapy for recurrent or metastatic squamous cell carcinoma of the head and neck(KEYNOTE-048); a randomised, open-label , phase 3 study.
Lancet,2019,394(10212):1915-1928
In order to improve the understanding of the majority of oncologists on the immunotherapy of head and neck tumors, Dr.
Sun Yao from the Department of Radiotherapy at the Cancer Hospital of Tianjin Medical University shared a case of recurrent laryngeal cancer for readers.
Case profile Medical history and auxiliary examination: A 62-year-old male patient with a complaint of "Goiter was found for 2 weeks" and was admitted to the hospital on June 16, 2020.
History of present illness: A neck mass was found for 2 weeks to see a doctor.
A neck ultrasound showed a solid mass in the left lobe of the thyroid, which was suspiciously malignant.
The patient had no hoarseness, coughing and other discomforts.
Past history: Partial laryngectomy was performed in 2016 due to early glottic carcinoma.
During the operation, the right vocal cord + anterior joint + left vocal cord anterior part were removed en bloc.
Postoperative pathology showed: laryngeal squamous cell carcinoma.
Physical examination: There is a mass in the left thyroid area, about 3.
5cm×2.
5cm, with tough texture, clear borders, no tenderness, moving up and down with swallowing, and no obvious mass in the right thyroid.
Both necks are not significantly enlarged lymph nodes.
Auxiliary examination: B-ultrasound indicates a solid mass in the left lobe of the thyroid-suspicious malignancy (Grade 4b), combined with biopsy is recommended; a solid nodule in the upper and middle left lobe of the thyroid, considering the possibility of nodular goiter (Grade 3).
The treatment passed the first stage of treatment: considering the possibility of thyroid cancer, the left thyroidectomy + left central cervical lymph node dissection under general anesthesia was performed on June 18, 2020.
The postoperative pathology showed: (After laryngeal cancer, Left lobe of thyroid) squamous cell carcinoma, considered metastatic in combination with medical history, originated from the larynx; left deep lymph node of the neck (+) with vascular tumor thrombus; no cancer metastasis, soft tissue in the left central lymph node (+): 0/ 4.
Soft tissue (+).
Immunohistochemistry: P63 (+), CK5/6 (+), P16 (-), EGFR (+), Ki-67 (30-40%+).
On July 2, 2020, a PET-CT examination showed that after “laryngeal cancer” and “left thyroidectomy”, the left thyroid lobe was absent, and the left back of the larynx was equivalent to a soft tissue mass at the level of the original left thyroid lobe.
PET imaging shows radioactive concentration, which is considered to be metastasis, and the adjacent larynx wall is suspected to be affected, except for the trachea and esophagus.
Further bronchoscopy and esophagoscopy examination showed no abnormalities.
Figure 1 PET-CT examination results The second stage of treatment: from August 18 to September 24, 2020, local radiotherapy for recurrent lesions, using volumetric emphasis (VMAT) technology, PGTV 69.
96Gy/33F.
The PD-L1 test was performed, and the CPS score was 2.
During radiotherapy, two cycles of concurrent cisplatin chemotherapy (80mg/m2) and concurrent teriprizumab (240mg) were given.
The radiotherapy process went smoothly.
Figure 2 Cervical CT results of 50Gy radiotherapy during treatment review: comparison with the PET-CT results on July 2, 2020: the laryngeal, left posterior, and left thyroid masses are larger than before, and the trachea and esophagus are not affected.
There is no obvious change.
Figure 3 The results of PET-CT during radiotherapy at 50Gy were re-examined on November 2, 2020.
The results suggest that compared with the CT results of the neck on September 10, 2020, there are more tumors in the laryngopharyngeal and left posterior and left thyroid areas.
The front has shrunk, and there is no obvious change in the rest.
Figure 4 The results of the neck CT review on November 2, 2020.
On January 12, 2021, the PET-CT review showed complete remission.
The results of PET-CT showed that compared with the results of PET-CT on July 2, 2020, the soft tissues of the left side of the trachea and the trachea and the esophagus in the original operation area were reduced after the "left thyroid lobe metastasis".
This PET imaging The degree of radioactive concentration is lower than before, suggesting that the metabolism of the lesion is lower than before.
Figure 5 PET-CT reexamination results on January 12, 2021, the patient's single-agent teriprizumab treatment has been maintained so far.
Case analysis The patient is a relapsed laryngeal cancer.
He was diagnosed with early glottic laryngeal cancer 4 years ago and underwent radical surgery.
Recurrence of cervical lymph nodes occurred 4 years after surgery.
Because the metastatic lymph node invaded the left lobe of the thyroid, when I went to surgery, I mistakenly considered a goiter and underwent radical thyroidectomy.
The postoperative pathology suggested squamous cell carcinoma.
Considering metastasis based on the previous medical history, further PET-CT examination was performed to confirm that it was laryngeal cancer.
Postoperative recurrence, after radiotherapy combined with immunotherapy for the recurring lesions, complete remission was obtained, and subsequent immunotherapy has been maintained for 8 months.
This case is a successful trial of radiotherapy combined with immunotherapy in recurrent head and neck squamous cell carcinoma.
The main adverse reactions in patients with radiotherapy combined with immunotherapy were second-degree radiation mucositis and first-degree radiation dermatitis, which were mainly related to radiotherapy.
No aggravation of mucositis caused by radiotherapy combined with immunotherapy was observed, and no immune-related adverse reactions were observed.
Appears, overall safety and well tolerated.
Expert comments based on the results of KEYNOTE-0481, suggesting that for recurrent/metastatic head and neck squamous cell carcinoma, combined immune chemotherapy is better than traditional targeted combined chemotherapy in the whole population, and in patients with PD-L1 CPS≥1, PD -1 monoclonal antibody also outperforms the traditional EXTREME regimen, especially for patients with CPS ≥ 20, compared with standard treatment, the 4-year survival rate of PD-1 monoclonal antibody is nearly three times higher (21.
6% vs 8.
0%), with a median total The survival time was extended from 10.
7 months to 14.
9 months, reducing the risk of death from the disease by 39% (HR=0.
61).
Based on the conclusions of this study, the first-line treatment of recurrent and metastatic head and neck squamous cell carcinoma has been completely changed.
The first-line treatment plan of PD-1 monoclonal antibody or combination chemotherapy has also been recommended by experts in the 2021 version of the CSCO guidelines.
For patients with recurrent head and neck squamous cell carcinoma that can be treated with local radiotherapy, the exploration of radiotherapy combined with immunotherapy for recurrent foci is still in progress, and a number of studies are currently being enrolled.
This case preliminarily confirmed that radiotherapy combined with teriprizumab in recurrent head and neck squamous cell carcinoma achieved good results.
It is hoped that more studies can further confirm the effect of this treatment model and bring more benefits to patients with recurrent head and neck squamous cell carcinoma.
Benefit more. References; 1.
BURTNESS B, HARRINGTON KJ, GREIL R, et al.
Pembrolizumab alone or with chemotherapy versus cetuximab with chemotherapy for recurrent or metastatic squamous cell carcinoma of the head and neck(KEYNOTE-048); a randomised, open-label , phase 3 study.
Lancet,2019,394(10212):1915-1928
